某院眼、耳疾病易出现错误的编码分析  

Analysis of Error ICD Coding of Eye and Ear Diseases in a Hospital

作　　者：孙鹏[1] Sun Peng(Medical Record Department of Beijing Tongren Hospital,Capital Medical University,Beijing 100730,China)

机构地区：[1]首都医科大学附属北京同仁医院病案科,北京市100730

出　　处：《中国病案》2020年第4期37-39,共3页Chinese Medical Record

摘　　要：目的分析2019年眼、耳疾病的诊断编码情况,找出容易发生错误的编码,从而提高编码质量。方法利用病案信息查询系统调取某院2019年主要诊断为眼睑内翻和倒睫、晶状体脱位、牵拉视网膜脱离、慢性化脓性中耳炎、慢性化脓性中耳炎胆脂瘤型的病案共1902例,由资深编码员依据编码原则和病案资料,对检索出来的病案编码进行审核。结果 1902例病案中编码错误332例,错误率为17%。其中错误主要体现在编码员未注意到后天性睑内翻和倒睫编码不包括先天性,指出病因的晶状体脱位并未细化编码,增殖性玻璃体视网膜病和牵拉视网膜脱离未联合编码,未仔细阅读慢性化脓性中耳炎的病案导致分型错误。结论眼、耳疾病编码容易出现编码错误,尤其要注意疾病的不同类型和病因,应全面了解病案资料再进行编码。Objective This paper analyzes the diagnosis coding of eye and ear disease medical records in a hospital in 2019,and the recomparison before and after the audit,so as to improve the coding quality.Methods Using the medical record information inquiry system,1902 cases of cholesteatoma with eyelid entropion and trichiasis,lens dislocation,traction retinal detachment,chronic suppurative otitis media and chronic suppurative otitis media were selected from a hospital in 2019.The analysis was carried out by using the methods of comparison before and after and chart comparison.Results 332 cases of coding errors were found in 1902 medical records,the error rate was 17%.The main mistakes are that the coder didn’t notice that the acquired entropion and trichiasis code didn’t include the congenital,pointed out that the lens dislocation of the cause didn’t refine the code,proliferative vitreoretinopathy and traction retinal detachment didn’t combine the code,and didn’t carefully read the medical records of chronic suppurative otitis media,which led to the classification errors.Conclusions The coding errors of eye and ear diseases are easy to occur,especially pay attention to the different types and causes of diseases,and comprehensively understand the data of medical records for coding.

关 键 词：眼、耳疾病 主要诊断 ICD编码 

分 类 号：R197.323[医药卫生—卫生事业管理]